Problems Of The Disc - And Is it a Big Risk?

Hello and welcome to Orthopaedics Made Simple , Making No Bones About It. And this is Naveen , Your Bone and Joint Guy.

The bones that form the back (spine) are called vertebrae. And between these vertebrae , there are soft gel filled  like structures called intervertebral discs. There are 23 in number . 6 in the neck , 12 in the upper back and 5 in the lower back. These  basically act like shock absorbers for the spine.

And today we will be discussing about the problems caused by the discs and the ways to deal with it.

The Disc is actually like a jelly doughnut like structure that exactly fits the size of the vertebral body ,both above and below it, It has an outer tough layer that holds the jelly like substance inside.

As one ages the fluid content in the inner jelly reduces and the outer tough layer too becomes dry and susceptible to cracks and this leads to most of the problems in the disc.

The Degenerated disk is the one that loses the water content , becomes brittle and can get cracked , look at the picture above. And once that happens the bones lose the cushioning and can rub against each other and undergo wear and tear. 

The other type of disc problem is the jelly like inside can make it's way out of a tear in the outer layer and press up on the structures that are close by. Depending on the level of leakage and compression it can be called a bulging disc or herniated disc. The structure that is commonly compressed upon is the nerve that comes from the spinal cord and it can cause pain or symptoms due to nerve function loss like loss of power or loss of sensation to the area that the nerve supplies.

Complaints:

The most common complaint of a patient due to disc problems is Pain. This pain is of two types. One is the direct pain of damaged or degenerated disc. This is localised and also a pressure on the corresponding area elicits tenderness. Movements of the spine like bending can cause pain The other pain is the radiating pain due to the nerve compression. This pain is along the area that the nerve supplies and can be confirmed by aggravating the nerve compression. For instance lifting the patients leg can aggravate the pain along the buttocks , a sign of compression to the nerves supplying that area. This pain is what is called Sciatica.

The other complaints are all due to nerve compression and are the ones that have to be monitored closely and acted upon aggressively if needed. They include loss of sensation to specific areas supplied by the nerves. The other is loss of power or weakness in the muscles supplied by the nerves that are compressed. Sometimes Urinary problems like loss of bladder control or loss of sensation of fullness bladder can happen if the disc prolapse happens in the areas from where those nerves are.

Causes:

Now why does this happen. Firstly the degenerated disc is a part of the general ageing process. But nobody can say for sure why bulging or herniation happens. As a matter of a fact less than 10% of the patients who have disc problem will exhibit symptoms. In other words a significant percentage of the "normal" population has a disc bulge visible on imaging studies. Obesity is a contributor. The type of work which involves straining the spine like bending or lifting loads can be a contributor. And trauma also is a reason that can cause this.

When to visit a doctor:

If localised pain or discomfort are the only complaints then some over the counter pain medication for about 5 days and some rest refraining from physically hard work could settle the issue. But if the pain is severe , especially of the radiating variety and it persists beyond a week please visit the doctor.

And you have to visit the doctor immediately if there is significant loss of sensation or loss of power in the muscles. And it's a real emergency if there is bladder dysfunction and loss of emergency around the buttock area (saddle type) . This condition is called Cauda Equina syndrome which happens when the compression is slightly higher up in the lower back.

Management:

Pain medication is the starting point to handle the discomfort. And some patients get away with it. The pain killers can include ones that reduce the swelling and fluid collection (inflammation) or ones that act on the brain , opiod like drugs. Your physician is the best person to take a call. Muscle relaxants are also prescribed and in rare cases drugs that reduce anxiety and depression form a part of the prescription.

Lifestyle advice is also important and helps many people. Weight reduction , especially weight around the abdomen , has been proven to help people back issues. How to sit , how to stand , how to walk , how to lie down , how to get up , how to lift objects and what activities to avoid are all explained in great detail to the patient after evaluating their daily routine and work life.

The physiotherapist steps in various modalities like localised heat treatment to provide relief and also manipulation and massages. But the most significant thing that a physio can do is core strengthening exercises that help people overcome back pain related to disc issues.

The other modality that a physiotherapist may use is Traction. This basically is trying to pull the vertebrae apart using weights in the hope that it decompresses the pressure on the disc and helps to reduce the pain. No other treatment in orthopaedics produces as much debate as traction as some studies suggest very good results and the others say it is just a placebo (mental satisfaction) that people experience relief from as a natural subsiding of symptoms or due to pain medication and exercises.

These are all out patient procedures and most of the patients respond to this. They may have a repetition of symptoms in the future but they will respond to this and can get away from the next level of treatment that include minimally invasive and surgical procedures.

Who needs surgery?

As I have already mentioned above that a significant number of the normal population has some disc problem or the other that are visible on imaging , especially MRI. But they won't have any symptom. So this itself should be a clear indication that all discs do not cause problems and can be treated conservatively. And if at all you decide to operate , you must be absolutely sure that it is the disc which is causing the problem.

So the doctor will perform extensive clinical examinations and ask you to undergo investigations to confirm the diagnosis. The clinical examination has to be thorough so as to rule out other causes of back pain which can include kidney issues , uterus issues , infections , trauma and even Herpes in old people.

The investigations among others will include 

X Rays. - Even though the X rays would not reveal the disc , the spine alignment and other problems can like wear and tear be made out. In India TB is a cause of a lot of back pain.

CT Scan - A more detailed study on the vertebrae and joints.

Blood tests - to rule out other causes like infections and arthritis.

Nerve conduction studies - To see which nerves are affected and at which level and to what extent.

MRI - This is the confirmatory diagnostic modality and is usually prescribed when the surgeon more or less has decided to operate on the disc.

But please remember only a very few people need invasive procedures and that too only after exhausting all the conservative treatments as listed above. The only exception is the cauda equina syndrome that needs to be operated upon as soon as possible.

Epidural Steroids

This is injecting some Steroid and Local Anaesthetic in to the area of the nerve affected by the disc bulge. The logic being the symptoms of nerve compression are due to inflammation ( fluid collection  , pain , swelling ) response due to irritation and steroids are drugs that reduce the inflammation. So under X ray guidance usually in the operation room an injection is inserted in to affected area and these drugs are infiltrated. They take about 3 days to a week to act and some may need a repeat dose. How long will they provide relief is a big question. Some experience relief for a few days whereas others never have the symptoms again. If you are on blood thinners you may be asked to wait for a fw days and if there is an active infection this procedure is better avoided.

Surgery:

There are three methods of surgery that are in practise now. The most common is the Micro- Discectomy where the a small opening is made and the herniated part of the disc is removed and the compression removed. This is a near magical surgery if done on an indicated patient. They will have tremendous relief as they are wheeled out of the Operating room itself.

The next type of surgery is where the entire disc may have to be removed and is replaced by an artificial disc. Finally comes the surgery where a significant portion of the disc or multiple discs have to be removed and the spine appears unstable. In these conditions the two vertebrae are fused together and stabilised using rods and screws.

Caution:

We at SCOT believe that Disc bulge / herniation is a very common problem. Very few people with disc bulges experience symptoms. And even among those who experience symptoms very few need treatment. Among those who need treatment only a very few need surgery. To put it lightly , often it is joked the the most common indication for operating on a disc is "Surgeon needs to fund his vacation". Hope I am clear.

But remember that the patient needs to be patient as sometimes a surgeon will be forced to operate to safeguard his reputation. Any compression pain will go away immediately with surgery and the surgeon will be made to operate on a patient who is in a hurry , as he fears that the patient might go to another surgeon who will operate and provide immediate relief , making him look bad. But it could be a case where a major surgery could have been avoided , if the patient showed some patience.

That's it folks , I think I have covered nearly all aspects of Disc problems. In case you need more info please leave a comment or email to ScotBoneAndJoint@gmail.com. And you can also catch the podcast version of this topic on Anchor at www.anchor.fm/OrthoMadeSimple . At Anchor you will also find the list of other podcast channels where OrthoMadeSimple is available

www.Scotortho.com for more details.